European Journal of Cardiovascular Medicine

The coronavirus disease (COVID-19) pandemic has had a worldwide impact on the population, global economy and heath care systems. Whilst the spread of the virus has resulted in far-reaching consequences, the closure of schools and universities has led to innovative methods of delivering education, ensuring that students continue to receive teaching, albeit different methods of modality. (1)

The coronavirus pandemic has seen the introduction of novel methods of delivering education to medical students. Lectures have rapidly been developed to be delivered online as webinars using various platforms such as Zoom, with such technologically enhanced approaches already being proven to have high levels of engagement with medical students. It has also been reported that many medical students find e‐learning enjoyable.  (2)

This pandemic has resulted in a sea change toward online learning. Many universities have already taken initiatives to start web-based teaching using platforms such as Microsoft Teams and Zoom for teaching for medical students. E‐learning has been shown to help foster self‐learning and to be nearly as successful as traditional didactics. Medical education, particularly, at the medical school/undergraduate level, has been no exception. It has also been reported that many medical students find e‐learning enjoyable. Medical education, particularly, at the medical school/undergraduate level, has been no exception. (3)

 The COVID-19 pandemic has tested the limits of healthcare systems and challenged conventional practices in medical education. However, providing patient contact and clinical experience is still a challenge. Students can be invited into the virtual room to participate in history taking, observe virtual physical examination, be a part of decision-making, patient and family counseling, and planning of implementations of treatment plan. (4) 

Online learning is a newer concept in education, where electronic media or technology are used for learning. Online learning has been less frequently practiced in medical education in developing countries such as India citing lack of infrastructure, expertise and feasibility. (5) Traditional teaching including using printed material as resource material are identified as cornerstone for learning by most medical students versus internet-based or non-online computer-based learning. (6)

However, online learning has emerged as the only possible mode of education during COVID crisis for school and college students. Medical education is more challenging and stressful as it involves bedside and soft skills training which cannot get adequately represented through online learning. Therefore, the present study was conducted to assess the effectiveness of online learning among medical students during COVID-19.

This cross-sectional study was conducted in Department of Physiology, Dr. B.R. Ambedkar Medical College & Hospital, Bengaluru, Karnataka, India. This study has been approved by the institutional ethics committee (Reference no.EC-277). This was a questionnaire-based study and the questions were based on a pre-validated questionnaire from a study done in UK. The questions included general information of the student and related to advantages and disadvantages of online learning during COVID-19. There were 20 questions and were of various styles including 5-point Likert scale ranging from strongly disagree to strongly agree. Few questions had single answer and few had multiple answers. The study was done using google forms and the link for google form was shared through social media platforms and students were asked to fill the forms voluntarily. It was kept open for one week to gather data.

This study invited 300 undergraduate medical students belonging to 2^nd year, 3^rd and final year during 2022 of Dr. B.R. Ambedkar Medical College & Hospital, Bengaluru, Karnataka, India. In this study, a total of 270 undergraduate medical students were participated, among them, 2^nd year students were 94, 3^rd year students were 96 and final year students were 80. Informed consent was obtained from all the study participants. Data was downloaded from google form in Microsoft excel and was used for analysis. 

A questionnaire was formed on the effectiveness of online learning during COVID-19 for MBBS students. Out of 270 students, females were 159 (58.8%) and males were 111 (41.1%). Before COVID-19 pandemic, 95 (35.1%) of the students never used online platforms for learning whereas 86 (31.8%) were using to some extent and 87 (32.2%) were using to great extent.

When students were asked about most effective method of online learning, their first priority was combined videos and tutorials then followed by you tube videos and live tutorials alone. 

When they were asked if teaching was stimulating, 46 (17%) of them disagreed, 148 (54.8%) were neutral and 76 (28%) students agreed to that. When asked if it was easy to concentrate on online lectures, 120 (44.4%) strongly disagreed, 81 (30%) were neutral and 69 (25.5%) agreed to that. Students felt 121 (44.8%) free to ask doubts during online lectures than offline. Majority of the students around 168 (62.2%) disagreed that online teaching was as effective as offline teaching and also around 151 (55.9%) of them preferred offline teaching (table 1 & figure 1).

Table 1: Students’ perceptions on their experiences of online teaching, ranked on a Likert scale. Likert scores have been shown as number and percentage.

When students were asked to choose the advantageous aspects of online learning, most of them (82%) opted for no travel, 50% of them said that they were more comfortable and were able to learn at own pace. Some students also felt that it was more flexible and cost saving (Figure 2).

Figure 2: Advantageous aspects of online learning

Among various options provided for barriers to online learning, majority of them had problems with internet connection and many had family distractions. Lack of devices, lack of space and anxiety were other barriers faced by the students. Majority of the students (38.8%) felt that online learning cannot replace the clinical teaching by direct patient contact whereas 33% of them said it has replaced only to some extent, 15% agreed that it replaced to great extent and only 12% of them opined that online learning can completely replace offline clinical teaching.

In this, 41% of the students were not able to learn clinical skills through online demonstrations whereas 47% were able to learn only to some extent and 10% of them to great extent (Figure 3).

Figure 3:  clinical skills through online

In the present study, online learning was the first priority, combined with videos and tutorials then followed by you tube videos and live tutorials. In support of our findings, a study conducted by Coman et al., reported that online learning fosters deeper understanding among students compared to traditional teaching. This improved understanding can help the students to perform better. (7)

When they were asked if teaching was stimulating, 46 (17%) of them disagreed, 148 (54.8%) were neutral and 76 (28%) students agreed to that. In a study by Mukhtar et al., reported that students’ performance through online learning is expected to deteriorate due to problems with technology and lack of communications with instructors whenever the students face difficulties grasping the learning content. Students also stated that they had difficulty paying attention during lectures. (8) Similarly, another study by Hurlbut et al., reported that students perform better in physical classes compared to online ones. (9) Yet, other studies by Sintema et al., and Şen HŞ., reported that students’ academic performance is significantly affected by their presence in physical classes, as in-person individual activities are essential for students to comprehend the subject matter. (10,11)

When asked if it was easy to concentrate on online lectures, 120 (44.4%) strongly disagreed, 81 (30%) were neutral and 69 (25.5%) agreed to that. Students felt 121 (44.8%) free to ask doubts during online lectures than offline. Majority of the students around 168 (62.2%) disagreed that online teaching was as effective as offline teaching and also around 151 (55.9%) of them preferred offline teaching. In this, 41% of the students were not able to learn clinical skills through online demonstrations whereas 47% were able to learn only to some extent and 10% of them to great extent. 

As suggested Rasmitadila et al., reported that students tend to lose attention during online learning sessions due to a variety of factors including family distractions and the lack of a conducive setting for learning. (12) Another study Gustiani et al., online learning caused\some students to lose motivation in their studies. This might occur due to a couple of factors including unfavourable learning environments. (13)

This study utilized retrospective cohort studies to examine students’ questioning behaviour in face-to-face versus online classes. According to the findings, students are more likely to ask questions during online learning than during face-to-face learning. The queries asked by students are also more complicated. The researchers concluded that this was the case as students do not need to raise their hands or speak directly to instructors to ask a question in an online learning setting. Instead, they can type their questions in the chat box and submit them anonymously. A timid student who constantly hesitates to ask questions during physical in-person class can benefit from these tools as they provide the much-needed anonymity. The chat or question box will remain visible until the end of the session, which allow other students to respond to the question or participate in the discussion. (14)

Students also reported that online learning has helped them to be more motivated in learning. This is the case as students were reported to feel more excited in learning to use new tools - such as new technologies that can be used to assist them during studying - effectively boosting their motivation.  (13) Most studies agreed that online learning could help students improve their skills such as communication and clinical skills. Two studies stated that online learning improves the former, while five studies suggested that it improves the latter. According to results obtained from Gormley et al. online learning had a positive impact on students’ clinical skills (15)

Among various options provided for barriers to online learning, majority of them had problems with internet connection and many had family distractions. Lack of devices, lack of space and anxiety were other barriers faced by the students. Majority of the students (38.8%) felt that online learning cannot replace the clinical teaching by direct patient contact whereas 33% of them said it has replaced only to some extent, 15% agreed that it replaced to great extent and only 12% of them opined that online learning can completely replace offline clinical teaching. 

This has directly impacted students performances in their clinical practices. Some students also mentioned that they are worried that missing physical clinical training during their degrees might lead them to lose their job opportunities in the future. (16) This challenge is further exacerbated as some students also lack familiarity with technology and often encounter technological issues such as incompatibility of online learning software with their computer’s operating system and the browsers they use. In addition, some cell phones can only support a limited number of applications. (17) According to Sitzmann et al., students’ learning outcomes might be significantly impacted by technical difficulties leading to an increase in students’ displeasure. (18)

The biggest challenge to implement online learning as observed in India is the lack of accessibility. This implies that more than half of the population lacked access to the internet during the pandemic. Most Indian families face financial difficulties that hinder their children from having their own equipment such as laptops, PCs, and cell phones for online learning use. Some families with multiple children also reported having difficulties enrolling themselves in online programs and lessons, as the entire family depends on a single gadget at home that must be shared with everyone. (19)

The present study may conclude that majority of the students used online platform during COVID 19. Online learning in medical education is a relatively new concept and one which is rapidly expanding. Online teaching has enabled the continuation of medical education during these unprecedented times. Moving forward from this pandemic, in order to maximise the benefits of both face-to-face and online teaching and to improve the efficacy of medical education in the future. Further studies with large sample size are recommended.

Conflict of interest: Nil

Funding: Nil

Acknowledgements: We would like to thank authorities of Dr. B.R. Ambedkar Medical College & Hospital, Bengaluru, Karnataka, India and also Meghana Swamy for her support during data collection. 

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